| National Nutrition Survey 2011
i
F
Pakistan
National Nutrition Survey 2011
Supported by:
UNICEF Pakistan
Draft May 2012
Aga Khan University, Pakistan
Pakistan Medical Research Council (PMRC)
Nutrition Wing, Ministry of Health, Pakistan
| National Nutrition Survey 2011
ii
INDEX
List of tables ----------------------------------------------------------------- ---------------------------------------- v
List of figures ---------------------------------------------------------------- ---------------------------------------- v
Acronyms------ --------------------------------------------------------------- ---------------------------------------- viii
General definitions -------------------------------------------------------- ---------------------------------------- x
Reference ranges for biochemical assessments---------------------- ------------------------------------------ xii
Executive summary -------------------------------------------------------- ---------------------------------------- xiii
CHAPTER 1: Introduction ------------------------------------------------- ---------------------------------------- 1
1.1 Introduction ------------------------------------------------------------ ---------------------------------------- 1
1.2 Context of malnutrition ----------------------------------------------- ---------------------------------------- 1
1.3 Need for a National Nutrition Survey ----------------------------- ---------------------------------------- 5
1.4 Survey duration -------------------------------------------------------- ---------------------------------------- 6
CHAPTER 2: Survey Design and Methods ----------------------------- ---------------------------------------- 7
2.1 Objectives ---------------------------------------------------------------- ---------------------------------------- 7
2.2 Indicators for the National Nutrition Survey --------------------- ---------------------------------------- 7
2.2.1 Anthropometric indicators ----------------------------------------- ---------------------------------------- 7
2.2.2 Clinical indicators ---------------------------------------------------- ---------------------------------------- 7
2.2.3 Biochemical indicators ---------------------------------------------- ---------------------------------------- 7
2.3 Survey design ----------------------------------------------------------- ---------------------------------------- 8
2.3.1 Universe --------------------------------------------------------------- ---------------------------------------- 8
2.3.2 Sampling frame ------------------------------------------------------- ---------------------------------------- 8
2.3.3 Listing activity -------------------------------------------------------- ---------------------------------------- 9
2.3.4 Stratification --------------------------------------------------------- ---------------------------------------- 9
2.3.5 Sample size and its allocation ------------------------------------- ---------------------------------------- 10
2.3.6 Sample selection procedure --------------------------------------- ---------------------------------------- 10
2.3.7 Target population ---------------------------------------------------- ---------------------------------------- 11
2.3.8 Survey methods ----------------------------------------------------- ---------------------------------------- 11
2.3.9 Description of questionnaire (quantitative) -------------------- ---------------------------------------- 11
2.3.10 Description of qualitative research ---------------------------- ---------------------------------------- 12
2.3.11 Qualitative research sample and target population -------- ---------------------------------------- 12
2.3.12 Transcription and translation of qualitative data ------------ ---------------------------------------- 12
2.3.13 Biochemical analysis ----------------------------------------------- ---------------------------------------- 12
2.3.14 Project pre-implementation steps ------------------------------ ---------------------------------------- 13
2.3.15 Identification and recruitment of field staff ----------------- ---------------------------------------- 13
2.3.16 Survey teams -------------------------------------------------------- ---------------------------------------- 13
2.3.17 Training -------------------------------------------------------------- ---------------------------------------- 14
2.3.18 Coding scheme for assigning processing codes -------------- ---------------------------------------- 15
2.3.19 Plan of operation, training and monitoring ------------------- ---------------------------------------- 16
2.3.20 Data management, transfer and analysis plan --------------- ---------------------------------------- 16
2.3.21 Ethical approval and confidentiality --------------------------- ---------------------------------------- 16
RESULTS OF THE NATIONAL NUTRITION SURVEY ------------------- ---------------------------------------- 17
CHAPTER 3: Background and Household Characteristics---------------------- ----------------------------- 18
3.1 Completion of data collection -------------------------------------- ---------------------------------------- 18
3.1.1 Blood and urine specimen ----------------------------------------- ---------------------------------------- 19
3.2 Background and household characteristics ----------------------- ---------------------------------------- 19
3.3 Formal education – head of household and mothers ---------- ---------------------------------------- 19
| National Nutrition Survey 2011
iii
3.4 Occupation – head of household ----------------------------------- ---------------------------------------- 20
3.5 Nature of dwelling by type of floor, roof and walls ------------- ---------------------------------------- 20
3.6 Type of cooking fuel -------------------------------------------------- ---------------------------------------- 22
3.7 Water sanitation and hygiene indicators ------------------------- ---------------------------------------- 22
3.7.1 Source of drinking water ------------------------------------------ ---------------------------------------- 22
3.7.2 Water treatment ---------------------------------------------------- ---------------------------------------- 23
3.7.3 Hygiene and sanitation -------------------------------------------- ---------------------------------------- 24
CHAPTER 4: Food Insecurity in Pakistan ------------------------------- ---------------------------------------- 26
4.1 Food secure ------------------------------------------------------------- ---------------------------------------- 26
4.2 Food insecure without hunger -------------------------------------- ---------------------------------------- 27
4.3 Food insecure with hunger (moderate) --------------------------- ---------------------------------------- 27
4.4 Food insecure with hunger (severe) ------------------------------- ---------------------------------------- 27
CHAPTER 5: Maternal Health and Nutrition -------------------------- ---------------------------------------- 29
Section 1: Basic data – age, education and marital status of mothers-------------- -------------------- 29
5.1.1 Age distribution ------------------------------------------------------ ---------------------------------------- 29
5.1.2 Marital status and current pregnancy status------------------- ---------------------------------------- 29
Section 2: Reproductive history and antenatal care --------------- ---------------------------------------- 29
5.2.1 Reproductive history ------------------------------------------------ ---------------------------------------- 29
5.2.2 Antenatal care -------------------------------------------------------- ---------------------------------------- 29
Section 3: Knowledge of micronutrients and micronutrient rich foods --------------------------------- 33
5.3.1 Knowledge of micronutrients ------------------------------------- ---------------------------------------- 33
5.3.2 Knowledge of vitamin rich foods --------------------------------- ---------------------------------------- 34
5.3.3 Knowledge about iodized salt and its usage ------------------- ---------------------------------------- 34
5.3.4 Consequences of micronutrient deficiencies ------------------ ---------------------------------------- 35
Section 4: Clinical examination ----------------------------------------- ---------------------------------------- 36
Section 5: Anthropometry ------------------------------------------------ ---------------------------------------- 36
Section 6: Micronutrient deficiency ------------------------------------ ---------------------------------------- 37
Section 7: Biochemical analysis ----------------------------------------- ---------------------------------------- 39
5.7.1 Anaemia (haemoglobin levels) ------------------------------------ ---------------------------------------- 39
5.7.2 Iron deficiency (Ferritin levels) ------------------------------------ ---------------------------------------- 40
5.7.3 Vitamin A deficiency ------------------------------------------------ ---------------------------------------- 40
5.7.4 Zinc deficiency -------------------------------------------------------- ---------------------------------------- 41
5.7.5 Calcium deficiency --------------------------------------------------- ---------------------------------------- 42
5.7.6 Vitamin D deficiency ------------------------------------------------ ---------------------------------------- 43
Section 8: Qualitative findings on perceptions regarding health and illness (mother and child) 44
CHAPTER 6: Child Health and Nutrition ------------------------------- ---------------------------------------- 45
Section 1: Nutrition status of children --------------------------------- ---------------------------------------- 45
6.1.1 Children 0–59 months ---------------------------------------------- ---------------------------------------- 45
6.1.2 Anthropometry (children under 5 years of age) --------------- ---------------------------------------- 45
6.1.3 Stunting (children under 5 years of age) ------------------------ ---------------------------------------- 46
6.1.4 Wasting (children under 5 years of age) ------------------------ ---------------------------------------- 46
6.1.5 Underweight (children under 5 years of age) ------------------ ---------------------------------------- 47
6.1.6 National trends in malnutrition ---------------------------------- ---------------------------------------- 48
6.1.7 Education of mothers and its effect on nutritional status of children ----------------------------- 48
6.1.8 Malnutrition trends in children under 5 years of age – SAARC countries comparison --------- 49
Section 2: Biochemical assessment ------------------------------------ ---------------------------------------- 50
6.2.1 Anaemia --------------------------------------------------------------- ---------------------------------------- 51
| National Nutrition Survey 2011
iv
6.2.2 Iron deficiency (low ferritin levels) ------------------------------- ---------------------------------------- 52
6.2.3 Vitamin A deficiency in children (under 5 years) -------------- ---------------------------------------- 52
6.2.4 Zinc deficiency -------------------------------------------------------- ---------------------------------------- 53
6.2.5 Vitamin D deficiency ------------------------------------------------ ---------------------------------------- 54
6.2.6 Urinary iodine excretion in children 6–12 years -------------- ---------------------------------------- 55
6.2.7 Clinical examination of children under 5 years of age ------- ---------------------------------------- 55
6.2.8 Distribution of low birth weight ---------------------------------- ---------------------------------------- 56
Section 3: Child immunization ------------------------------------------- ---------------------------------------- 56
Section 4: Child morbidity ------------------------------------------------ ---------------------------------------- 59
6.4.1: Prevalence of acute respiratory infections -------------------- ---------------------------------------- 60
6.4.2: Prevalence of diarrhoea ------------------------------------------- ---------------------------------------- 60
CHAPTER 7: Infant and Young Child Feeding Practices ------------ ---------------------------------------- 62
CHAPTER 8: Food Intake and Practices -------------------------------- ---------------------------------------- 67
Section 1: Food consumption by children 0–23 months of age -- ---------------------------------------- 67
8.1.1 Comparison of nutrient intake with the recommended dietary allowance (RDA) -------------- 67
8.1.2 Consumption of food groups- mothers ------------------------- ---------------------------------------- 67
Section 2: Food consumption in mothers ----------------------------- ---------------------------------------- 69
8.2.1 Comparison of nutrient intake with the RDA ------------------ ---------------------------------------- 69
8.2.2 Consumption of food groups - mothers ------------------------- ---------------------------------------- 69
Section 3: Qualitative findings on food intake, practices and buying behaviour --------------------- 70
8.3.1 Common perception and physiological effects of “hot” and “cold” foods ------------------------ 70
8.3.2 Health care provider’s viewpoint on food intake ------------- ---------------------------------------- 70
8.3.3 Purchasing practices ------------------------------------------------ ---------------------------------------- 70
8.3.4 Intra household food distribution -------------------------------- ---------------------------------------- 71
8.3.5 Differences in dietary intake between girls and adult women -------------------------------------- 72
8.3.6 Food safety – thawing and food storage ----------------------- ---------------------------------------- 72
CHAPTER 9: Elderly Persons Health and Nutritional Status ------- ---------------------------------------- 73
Chapter 10: What Next? -------------------------------------------------- ---------------------------------------- 76
Bibliography ----------------------------------------------------------------- ---------------------------------------- 78
Credits ------------------------------------------------------------------ ---------------------------------------- 82
Annex: NNS Detailed Tables --------------------------------------------- ---------------------------------------- 83
| National Nutrition Survey 2011
v
List of Tables
Table 2.1: Enumeration blocks and villages --------------------------- ---------------------------------------- 9
Table 2.2: Sample size and allocation plan ---------------------------- ---------------------------------------- 10
Table 2.3: Description of biochemical analysis/tests ---------------- ---------------------------------------- 12
Table 2.4: Pre-implementation steps ----------------------------------- ---------------------------------------- 13
Table 2.5: Details of training agenda ------------------------------------ ---------------------------------------- 14
Table 3.1: Details of sample size coverage ---------------------------- ---------------------------------------- 19
Table 6.1: Vaccination by source of information -------------------- ---------------------------------------- 57
Table 8.1: Breakdown of calories and nutrients consumed by children 0–23 months (24 hours food
recall) -------------------------------------------------------------------------- -------------------------------------------67
Table 8.2: Breakdown of calories and nutrients in mothers (24 hours food recall) -------------------- 69
List of Figures
Fig: 3.1 Population density ------------------------------------------------ ---------------------------------------- 19
Fig: 3.2 National Nutrition Survey coverage --------------------------- ---------------------------------------- 19
Fig: 3.3 Formal education of mother ----------------------------------- ---------------------------------------- 20
Fig: 3.4 Nature of dwelling – materials used for construction ----- ---------------------------------------- 21
Fig: 3.5 Nature of dwelling- urban/rural comparison of materials used for construction ------------ 22
Fig: 3.6 Source of fuel for cooking -------------------------------------- ---------------------------------------- 22
Fig: 3.7 Source of drinking water ---------------------------------------- ---------------------------------------- 23
Fig: 3.8 Households do not treat water to make it safer ------------------ ---------------------------------- 23
Fig: 3.9 Water treatment methods ------------------------------------- ---------------------------------------- 24
Fig: 3.10 Households using sanitation facilities ---------------------- ---------------------------------------- 24
Fig: 3.11 Type of toilet facilities ------------------------------------------ ---------------------------------------- 25
Fig: 4.1 Food insecurity situation --------------------------------------- ---------------------------------------- 27
Fig: 5.1 Antenatal care during last pregnancy ------------------------ ---------------------------------------- 30
Fig: 5.2 ANC from skilled care provider -------------------------------- ---------------------------------------- 31
Fig: 5.3 Antenatal care visits (four or more) -------------------------- ---------------------------------------- 31
Fig: 5.4 Components of care during ANC visits ----------------------- ---------------------------------------- 32
Fig: 5.5 Micronutrient supplementation during last pregnancy --- ---------------------------------------- 33
Fig: 5.6 Knowledge about micronutrients ------------------------------ ---------------------------------------- 33
Fig: 5.7 Level of iodine content in salt --------------------------------- ---------------------------------------- 35
Fig: 5.8 Clinical examination of mothers (comparison between NNS 2001-NNS 2011) --------------- 36
Fig: 5.9 Body Mass Index -------------------------------------------------- ---------------------------------------- 37
Fig: 5.10 Median urinary iodine excretion in mothers -------------- ---------------------------------------- 38
Fig: 5.11 Comparison of night blindness in women ------------------ ---------------------------------------- 38
Fig: 5.12 Maternal anaemia ----------------------------------------------- ---------------------------------------- 39
Fig: 5.13 Comparison of anaemia in mothers ------------------------- ---------------------------------------- 40
Fig: 5.14 Ferritin Levels ---------------------------------------------------- ---------------------------------------- 40
Fig: 5.15 Vitamin A deficiency (pregnant women) ------------------- ---------------------------------------- 41
Fig: 5.16 Comparison of Vitamin-A deficiency among non-pregnant women (urban/rural) --------- 41
Fig: 5.17 Zinc deficiency (pregnant Women) -------------------------- ---------------------------------------- 42
Fig: 5.18 Zinc deficiency --------------------------------------------------- ---------------------------------------- 42
Fig: 5.19 Calcium deficiency (pregnant women) ---------------------- ---------------------------------------- 43
Fig: 5.20 Vitamin D deficiency (pregnant women) ------------------- ---------------------------------------- 43
Fig: 6.1 Household with children under five years of age ---------- ---------------------------------------- 45
Fig: 6.2 Prevalence of malnutrition in Pakistan (children under 5 years of age) ----------------------- 46
Fig: 6.3 National stunting rates (children under 5 years of age) --- ---------------------------------------- 46
| National Nutrition Survey 2011
vi
Fig: 6.4 National wasting rates (children under 5 years of age) --- ---------------------------------------- 47
Fig: 6.5 Underweight rates (children under 5 years of age) ------------------------------------------------- 47
Fig: 6.6 National malnutrition trends ---------------------------------- ---------------------------------------- 48
Fig: 6.7 Education of mothers and its effect on nutritional status of children -------------------------- 49
Fig: 6.8 SAARC countries national stunting trends ------------------- ---------------------------------------- 49
Fig: 6.9 SAARC countries national wasting trends -------------------- ---------------------------------------- 50
Fig: 6.10 SAARC countries national underweight Trends ----------- ---------------------------------------- 50
Fig: 6:11 Anaemia in children under 5 years of age ------------------ ---------------------------------------- 51
Fig: 6.12 Trends of prevalence of anaemia in children under 5 years of age ---------------------------- 51
Fig: 6.13 Iron deficiency among children ------------------------------- ---------------------------------------- 52
Fig: 6.14 Vitamin A deficiency ------------------------------------------- ---------------------------------------- 52
Fig: 6.15 Trend of vitamin A deficiency in children under 5 years - ---------------------------------------- 53
Fig: 6.16 Zinc deficiency in children (0-5 years) ----------------------- ---------------------------------------- 53
Fig: 6.17 Comparison of Zinc deficiency in children under 5 years of age -------------------------------- 54
Fig: 6.18 Vitamin D deficiency ------------------------------------------- ---------------------------------------- 54
Fig: 6.19 Median urinary iodine excretion in children 6–12 years ---------------------------------------- 55
Fig: 6.20 Distribution of low birth weight infants by mother recall (birth weight and size) ---------- 56
Fig: 6.21 Availability of vaccination cards ------------------------------ ---------------------------------------- 57
Fig: 6.22 Provincial reported pentavalent vaccine coverage ------- ---------------------------------------- 58
Fig: 6.23 Provincial percentage for availability of vaccination cards -------------------------------------- 58
Fig: 6.24 Immunization by source of information (mother’s recall and vaccination card) ----------- 59
Fig: 6.25 Current acute respiratory infection (ARI) status ---------- ---------------------------------------- 59
Fig: 6.26 Prevalence of diarrhoea ---------------------------------------- ---------------------------------------- 60
Fig: 6.27 Worm infestation among children -------------------------- ---------------------------------------- 61
Fig: 7.1 Initiation of breastfeeding within one hour ----------------- ---------------------------------------- 62
Fig: 7.2 Breastfeeding practices ----------------------------------------- ---------------------------------------- 63
Fig: 7.3 Continued breastfeeding 12-15 months --------------------- ---------------------------------------- 64
Fig: 7.4 Minimum dietary diversity (6–23 months) ------------------ ---------------------------------------- 64
Fig: 7.5 Minimum meal frequency (6–23 months) ------------------ ---------------------------------------- 65
Fig: 7.6 Minimum acceptable diet (6–23 months) ------------------- ---------------------------------------- 65
Fig: 7.7 Age appropriate breastfeeding (0–23 months) ------------ ---------------------------------------- 66
Fig: 9.1 Age distribution of elderly persons ---------------------------- ---------------------------------------- 73
Fig: 9.2 Gender distribution of elderly persons interviewed ------- ---------------------------------------- 74
Fig: 9.3 Loss of appetite in elderly persons ---------------------------- ---------------------------------------- 75
Fig: 9.4 Weight loss in elderly persons (by recall) -------------------- ---------------------------------------- 75
| National Nutrition Survey 2011
vii
Acronyms
AJK Azad Jammu and Kashmir
AKU Aga Khan University
ANC Antenatal care
ARI Acute respiratory infection
BCG Bacille Calmette-Guérin (vaccine against tuberculosis)
BMI Body Mass Index
CHW Community health worker
DHS Demographic health survey
DMU Data management unit
DPT Diphtheria-tetanus-pertussis
EB Enumeration block
EPI Expanded program for immunization
ERC Ethical Review Committee
FATA Federally Administered Tribal Areas
FBS Federal Bureau of Statistics
FGD Focus group discussion
FHI Family Health International
GB Gilgit Baltistan
GAIN Global Alliance for Improved Nutrition
Gm. Gram
HH Household
Hib Haemophilus influenzae type B
IDA Iron deficiency anaemia
IDI In-depth Interview
IYCF Infant and young child feeding
K. Cal Kilocalories
KAP Knowledge, attitude and practice
KP Khyber Pakhtunkhwah
LBW Low birth weight
LHV Lady health visitor
LHW Lady health worker
MDG Millennium Development Goal
Mg Milligram
Ml Millilitre
MOH Ministry of Health
MUAC Mid-upper arm circumference
MWRA Married women of reproductive age
NGO Non-governmental organization
NID National Immunization Day
NNS National Nutrition Survey
| National Nutrition Survey 2011
viii
OPV Oral polio vaccine
ORS Oral rehydration salt
PCO Population Census Organization
PDHS Pakistan Demographic Health Survey
PMRC Pakistan Medical Research Council
PPS Proportion to population size
PRSP Punjab Rural Support Program
PSU Primary sampling unit
RDA Recommended dietary allowance
SAARC South Asia Association of Regional Cooperation
SSU Secondary sampling unit
TBA Traditional birth attendant
UIE Urinary iodine excretion
UNICEF United Nations Children’s Fund
USAID United States Agency for International Development
VAD Vitamin A deficiency
WHO World Health Organization
WRA Women of reproductive age
| National Nutrition Survey 2011
ix
General Definitions
Body mass index (BMI): Statistical measure of weight scaled according to height, determined by
dividing a person’s weight by the square of their height in metric units. For adults, a BMI of less
than 18.5 typically indicates under nutrition, while a BMI of more than 40 indicates morbid
obesity.
Complementary feeding: This is the period starting when breast milk alone is no longer
sufficient to meet the nutritional requirements of infants. Other foods and liquids are needed to
complement breast milk at this stage. This transition from exclusive breastfeeding to family
foods typically covers the period from 6 months to 18-24 months of age.
Exclusive breastfeeding: The practice of only feeding breast milk to an infant with no
supplementation of any kind (e.g. no water, juice, food, or non-human milk). Exclusive
breastfeeding has been shown to provide improved protection against many diseases. According
to the World Health Organization, on a population basis, exclusive breastfeeding for six months
is the optimal way of feeding infants. Thereafter infants should receive complementary foods
with continued breastfeeding up to two years of age or beyond. (Note: The NNS 2011 does not
include analysis of exclusive breastfeeding. It only measures rates of “predominant
breastfeeding.”)
Malnutrition: Various forms of poor nutrition leading to both underweight and overweight
conditions caused by a complex array of issues, including dietary inadequacy, infections, and
socio-cultural factors. Malnutrition can lead to wasting and stunting, micronutrient deficiencies,
as well as diabetes and other diseases.
Micronutrients: Nutrients needed for life in miniscule amounts. These substances enable the
body to produce enzymes, hormones and other substances essential for proper growth and
development. Micronutrients are used to improve nutrition through processes such as bio
fortification and supplementation.
Stunting: Failure to reach linear growth potential because of inadequate nutrition or poor
health, also defined as a chronic restriction of growth in height indicated by low height-for-age.
Stunting is usually a reliable indicator of long-term under nutrition among young children.
Supplementation: Process of supplying nutrients – in forms such as bars, capsules, and powders
– those missing or not consumed in a person’s diet. Typical supplements include vitamin A, iron,
and zinc.
Undernutrition: According to the 2008 Lancet series on maternal and child under nutrition,
under nutrition includes a wide array of effects including intrauterine growth restriction
resulting in low birth weight, underweight, stunting, wasting and less visible micronutrient
deficiencies. Under nutrition is caused by poor dietary intake that may not provide sufficient
nutrients, and/or by common infectious diseases such as diarrhoea. These conditions are most
significant during the first two years of life.
Underweight: This indicates a person has a low weight for their age and implies stunting or
wasting. The rate of underweight children is the percentage of children who have low weight for
their age.
| National Nutrition Survey 2011
x
Wasting: Acute weight loss indicated by a low weight for height ratio. Wasting is usually a result
of acute starvation or severe disease. Often more chronic during the first two years of life,
wasting is part of a pattern of under nutrition.
| National Nutrition Survey 2011
xi
Reference ranges for biochemical assessments
Biochemical Test
Children under 5 years Women of Reproductive Age
Non-pregnant
Women of Reproductive Age
Pregnant
Vitamin A Severe (0.70µmol/L)
Severe (0.70µmol/L)
Severe (0.70µmol/L)
Vitamin D
Severe deficiency (20.0 - 30.0 ng/mL)
Sufficient (>30.0 ng/mL)
Severe deficiency (20.0 - 30.0 ng/mL)
Sufficient (>30.0 ng/mL)
Severe deficiency (20.0 - 30.0 ng/mL)
Sufficient (>30.0 ng/mL)
Zinc Deficient (=60 µg/dL)
Deficient (
| National Nutrition Survey 2011
xii
Executive Summary
This section summarizes findings from Pakistan’s National Nutrition Survey. Aga Khan
University’s Division of Women and Child Health, Pakistan’s Ministry of Health and UNICEF
conducted the survey in 2011 for the first time in ten years. The survey assessed the overall
nutritional status of target groups based on anthropometric indices and micronutrient status.
The findings provide relevant information for planning, implementation and monitoring
appropriate population based interventions in Pakistan. Population groups surveyed included:
pre-school children (6–59 months old), school aged children (6–11 years old), women of
childbearing age (15–49 years old), and elderly persons (50 years and above).
This was the first time a National Nutrition Survey provided provincial specificity with
representative population based samples. A two stage stratified sampling design was adopted
and an overall sample size of 30,000 households was selected and calculated on the basis of
major nutrition indicators used in the 2001 NNS. These included: 1. Stunting in children and 2.
Anaemia in women of reproductive age (WRA) and in children. Households interviewed totalled
27,963; 24,421 blood samples were taken (women 12,282; children 12,139); and 2,917 urine
samples were collected from women (1,460) and children 6-12 years (1,457) for urinary iodine
assessments.
The NNS 2011 covered all provinces: Gilgit Baltistan (GB), Balochistan, Khyber Pakhtunkhwah
(KP), Sindh, Punjab, Azad Jammu and Kashmir (AJK) and the Federally Administered Tribal Areas
(FATA). This included 1,500 enumeration blocks (EBs)/villages and 30,000 households, with a
49% urban and 51% rural distribution. Renewed listing of all households in each enumeration
block was conducted and twenty households were selected randomly using a computer
automated selection process. Twenty-two survey teams conducted data collection across
Pakistan.
Results from the 2011 National Nutrition Survey (NNS) indicated little change over the last
decade in terms of core maternal and childhood nutrition indicators. With regard to
micronutrient deficiencies, while iodine status had improved nationally, vitamin A status had
deteriorated and there had been little or no improvement in other areas linked to micronutrient
deficiencies.
The ratio of males to females was approximately 50.4% to 49.6% across Pakistan. A total of
45.7% of household heads were illiterate and 38.7% were workers or farmers. 15.5% of the
population was unemployed – with higher rates in the urban population (17.5% urban
unemployment, 13.7% rural unemployment).
The NNS 2011 also revealed 58% of households were food insecure nationally. Sindh was the
most food-deprived province followed by Balochistan. 72% of families in Sindh and 63.5% in
Balochistan faced food insecurity.
| National Nutrition Survey 2011
xiii
Overall, 18% of women were underweight in Pakistan – 14.4% from urban areas and 19.7% from
rural areas. Only slightly over half (53.2%) of mothers had normal body mass indices (BMI).
Night blindness prevalence reported by women who were pregnant at the time of this survey
was 12.7% while night blindness prevalence reported by women during their last pregnancy was
15.6%. Approximately 42.8% of the population reported awareness of the importance of iodine
whereas 64.2% reported awareness about the benefits of iodized salt. Only 39.8% reported
using iodized salt whereas kit-testing results confirmed use at 69%. This is a significant
improvement over the 2001 NNS result of 17%. Overall knowledge of the importance of vitamin
A in Pakistan was 24%. Knowledge about other micronutrient deficiencies was very low with
significant rural and urban differences.
Widespread micronutrient deficiencies were found in women. For example, the survey
discovered the following micronutrient deficiency levels in pregnant women: Anaemia 50.4%,
iron deficiency anaemia 24.7%, vitamin A deficiency 42.5%, zinc deficiency 47.6%, hypocalcaemia
58.9% and vitamin D deficiency 68.9%. The prevalence of micronutrient deficiencies in non-
pregnant women were as follows: Anaemia 51%, iron deficiency anaemia 19%, vitamin A
deficiency 42.1%, zinc deficiency 41.3%, hypocalcaemia 52.1% and vitamin D deficiency
66.8%.Adequate iodine status was documented at national level and in most of the provinces.
Balochistan, AJK and GB were the only provinces that documented inadequate levels (
| National Nutrition Survey 2011
xiv
the preceding three months, 3.6% had restricted mobility and stayed mainly in their beds or
chairs due to ailments, and 49.6% suffered from arthritis.
The National Nutrition Survey 2011 indicates that stunting, wasting and micronutrient
malnutrition is endemic in Pakistan. These are caused by a combination of dietary deficiencies;
poor maternal and child health and nutrition; a high burden of morbidity; and low micronutrient
content in the soil, especially iodine and zinc. Most of these micronutrients have profound
effects on immunity, growth, and mental development. They may underlie the high burden of
morbidity and mortality among women and children in Pakistan. Increasing rates of chronic and
acute malnutrition in the country is primarily due to poverty, high illiteracy rates among mothers
and food insecurity. Such rates can also be attributed to inherent problems in infant feeding
practices and lack of access to the age-appropriate foods.
Chapter 1: Introduction
1.1. Introduction
Pakistan is a federal parliamentary republic consisting of four provinces – Balochistan, Khyber
Pakhtunkhwah, Punjab and Sindh – and four federal territories – the capital Islamabad, the
Federally Administered Tribal Areas (FATA), Azad-Jammu and Kashmir (AJK) and Gilgit Baltistan
(GB). Bordering India, China, Iran and Afghanistan, the country can be divided into the Indus
plain in the East, the mountainous area in the North and Northwest and the Balochistan plateau
in the West. [1]
Pakistan is the sixth biggest country in the world, with an estimated population of more than 180
million people. It has the second largest Muslim population of any single country after Indonesia.
Ranking 141 out of 182 countries in the Human Development Index (HDI), Pakistan is an
impoverished and underdeveloped country. Life expectancy at birth stands at 65 years and the
adult literacy rate is 49% (male 63%, female 36%).
Pakistan is a disaster-prone country and is exposed to a multitude of natural disasters including
earthquakes, floods, storms and droughts. [2-6]. The country was under military dictatorship for
33 of its 64-year existence.
The security situation in Pakistan is complex. There are a number of overlapping threats,
including the presence of non-state actors targeting government installations and security
forces, especially in the areas bordering Afghanistan. [4, 6]
1.2 Context of malnutrition
Estimates suggest that more than 150 million malnourished children around the world are under
5 years of age. It is also well recognized that half of the 12 million deaths among children under
5, or almost 54% of young child mortality in developing countries, can be linked to malnutrition.
[8] Studies suggest that malnutrition has a multiplicative effect on the risk of mortality from
infectious diseases. [9]
Like other major health issues, malnutrition is a prevalent problem in the South Asian region.
Half of the world’s malnourished women and children are found in just three countries:
Bangladesh, India and Pakistan. South Asia is the worst affected region and presents what has
been termed an “Asian Enigma” due to high rates of low birth weight (LBW), unhygienic
conditions, unsatisfactory breastfeeding and weaning practices and the poor status of women.
[10]
Malnutrition is a recognized health problem in Pakistan and plays a substantial role in the
country’s elevated child morbidity and mortality rates. Due to its correlation with infections,
malnutrition in Pakistan currently threatens maternal and child survival, especially in poor and
underdeveloped areas. However, there are concrete solutions, which depend on political will,
economic advancement and viable targeted research. [7]
| National Nutrition Survey 2011
2
The number of underweight children and women is very high in the South Asian region. About
one third of babies are underweight and more than half of women of reproductive age weigh
less than 45 kg. [11] It is believed that malnourished adult women have a much higher risk of
giving birth to low birth weight infants. Infants born with a low birth weight are at a higher risk
of morbidity and mortality in the neonatal period or later infancy, especially in developing
countries. [12] The infants who survive are often poorly breastfed and weaned, resulting in
stunted and malnourished children. These conditions result in children growing into adults who
are less prepared to contribute to society and productivity, thus adding to poverty and
unemployment in the country. Low birth weight women also develop into malnourished
mothers who give birth to LBW babies and perpetuate this cycle.
Stunting is used as a reliable indicator of growth retardation in developing countries. The
stunting rates in Pakistan fell from 47% in 1980 to about 33% in 2000. [13] It is estimated that
the most important factors associated with lower prevalence of stunting are the availability of
high-energy nutrients, female literacy and gross national product. [16] Challenges linked to these
factors are still serious in Pakistan and particularly affect children, young girls and women. [16]
Like other developing countries in South Asia, with the exception of Sri Lanka, the situation in
Pakistan linked to maternal and child under nutrition is serious. [18] Pakistan’s prevalence of
stunting declined from 67% in 1977 to an estimated 40-50% and remained at such levels until
the end of the 1990s. However, these rates are still very high when compared to the global
average. [19] According to the national survey (1990-94), among the urban middle to lower
economic group, the prevalence of stunting was approximately 30-36% and as high as 35-45% in
the same economic group in rural areas. [20] The national survey categorized economic status
on the basis of material possessions and facilities owned by the household. However, it used
different criteria for urban and rural households. Thus, Pakistan’s urban-rural difference may be
partially explained by the relatively higher level of education among the urban population as
well as their access to basic health services. [21]
Malnourished children begin to fall behind on their regular growth at around six months of age.
This is the time when an infant starts receiving complementary foods in addition to breast milk.
[22] The divergence from normal growth is linked to a combination of poor nutrition and intra-
uterine growth. [23] This problem is aggravated by the burden of morbidity. [24] Poor quality
and quantity of complementary foods and inadequate caring practices are the key determinants
for this early phase of childhood growth retardation, [25] which can lead to late onset of the
childhood growth spurt and subsequent retardation. [26] Growth faltering is linked to a series of
occurrences a child suffers, including repeated illnesses, inadequate appetite, insufficient food
intake and poor standard care. Many of these children die before their first birthday and those
who survive suffer long-term consequences such as weak stature and challenged mental
capacity. [27]
Pakistan’s economy is largely dependent on agricultural output. The country’s farmers cultivate
sufficient amounts of diverse crops to feed most of the population, which makes the degree of
malnutrition even more distressing. However, the issue of malnutrition has been a constant
| National Nutrition Survey 2011
3
challenge in Pakistan for decades. The micronutrient survey in 1976-1977 revealed that 60% of
children under 5 were malnourished. Widespread malnutrition in younger infants was further
highlighted by a survey of children under 2 years of age. [28] The results of these surveys were
confirmed by high rates of early childhood malnutrition from studies conducted in Lahore.
[29,30] The National Nutrition Survey that was conducted in 1985-87 further revealed that 48%
of children were malnourished and 10% were severely malnourished. The 2001-2002 National
Nutrition Survey also showed a dire malnutrition situation in Pakistan. This was the first time a
NNS highlighted the true extent and burden of macronutrient and micronutrient malnutrition in
the country. [31]
Widespread macronutrient malnutrition coupled with subclinical micronutrient deficiencies
prevail in South Asia and have been largely ignored in the region and in Pakistan. “Subclinical
deficiency” is micronutrient malnutrition without visible signs of deficiency, also termed as the
“hidden hunger”. It is estimated that more than seven million people suffer from clinical forms
of these micronutrient deficiencies and another 2 billion from subclinical forms. [32]
Various studies and surveys from Pakistan indicate that subclinical micronutrient deficiencies
such as iron-deficiency, zinc deficiency and vitamin A deficiency are widespread among pre-
school children and women of reproductive age, particularly pregnant women. [31] A survey
conducted with pre-school children in the North West Frontier Province (now Khyber
Pakhtunkhwa) revealed that about 50% of the children showed evidence of significant anaemia
and zinc deficiency. [33] Data on micronutrient malnutrition are scarce and limited. Only a few
studies have been conducted on a local scale and these cannot be relied upon to measure larger
scale issues. [34]
To implement successful strategies and sustainable interventions, the direct and indirect causes
of Pakistan’s huge malnutrition burden must be identified. The analysis below identifies some of
the determinants of malnutrition in Pakistan and the impact these factors have on the status of
malnutrition in the country.
More than 30% of Pakistan’s population lives below the poverty line. [35] The Gini coefficient,
used to measure economic inequality in a society (using the range of 0 to 1, “0” indicating
complete equality and “1” indicating complete inequality), is 0.410 in Pakistan. This shows a very
high rate of inequality. The poorest 20% of the population earn 6.2% of the country’s total
income and most households in Pakistan spend almost half of their income on food. Poor food
availability, poor quality of diet, and limited knowledge about nutritious foods all contribute to a
vicious cycle of malnutrition. Political issues, security issues linked to non-state actors and
unemployment in the country have amplified this problem. Another important risk factor
contributing to malnutrition is a high and repeated burden of infections. Repeated acute
respiratory infections (ARI), diarrhoea and other infections lead to a decrease in dietary intake
and nutrient use due to loss of appetite and reduced absorption. [36]
Poor breastfeeding and weaning practices are also common in Pakistan. As a result, infants do
not consume adequate calories, proteins and micronutrients. While almost 90% of women
| National Nutrition Survey 2011
4
breastfeed their children, very few start breastfeeding within one hour of birth and most of
them discard colostrum considering it as waste or impure milk that is not suitable for their
babies. The rate of exclusive breastfeeding in the first four months is only 16%. The current
number of mothers introducing complementary foods at the right time is low and poor food
choices commonly result in increased risk of diarrhoea and malnutrition. It is well known that
lack of awareness about proper nutrition and feeding practices, coupled with poor food choices,
trigger the widespread use of weaning diets with poor micronutrient content and bioavailability.
[37]
The fertility rate in Pakistan is very high. On average, Pakistani women give birth 6.8 times in
their lives. Approximately only 28% of women between 15 and 49 years of age use
contraception. A high fertility rate and lack of birth spacing result in a continuous cycle of
pregnancy and lactation. Such a cycle can deplete the body reserves of an already malnourished
mother.
The adult literacy rate in 2011 in Pakistan was low, 67% for males and 42% for females. It is
believed such low levels of education among women in Pakistan influence their reproductive
behaviour. It also makes reproduction related decisions in families and in society at large
principally dependent on men’s knowledge and practices. In general, women in Pakistan have
very little control over areas of life such as food distribution within household and family
planning. [38, 39]
Antenatal care plays a vital role in the wellbeing of mothers and growing children. The care a
mother receives during pregnancy and after delivery determines how well she will be able to
feed and care for her child. This includes breastfeeding, food preparation, general care, hygiene
and home health care. In Pakistan most pregnant mothers are unaware of the importance of
antenatal care and have limited access to health facilities. The use of antenatal health care
facilities is very low in the country and access has remained static over the years. To make
matters worse, in 2011 trained health personnel attended only 39% of births. [40]
The rates of malnutrition in children under 5 determined by the 2011 National Nutrition Survey
were as follows: wasting 13%, underweight 38% and stunting 37%. In the same survey about
13% of non-pregnant and 16% of pregnant women were reported to be malnourished
(BMI
| National Nutrition Survey 2011
5
potential of the society. Despite an increase in food availability over the past 20 years there has
been little change in the prevalence of malnutrition in the population. This may be related to the
cross-sectoral and complex nature of malnutrition, which includes issues related to poverty,
intra-household food security and contemporary socio-cultural factors determining dietary
patterns in pregnancy and early childhood.
1.3 Need for a National Nutrition Survey
National Nutrition Surveys provide an estimate of the severity and geographical scope of
nutrition related challenges in a country. They also expose problems closely linked to nutrition
issues and identify the most-at-risk groups. Nutrition surveys assess the likely evolution and
impact of nutrition levels on the health and nutritional status of the population at large while
taking into account secondary information such as food security and food distribution. They also
help identify what types of nutrition interventions would be most effective to prevent or
minimize the problem in the future. Governments use national surveys when deciding whether
or not to establish or expand existing nutrition surveillance and to ensure effectiveness and
monitor progress over time. To assess the magnitude of the problem, governments and partners
also look at the population size, demographic characteristics of the population and distribution
of malnutrition cases therein.
To understand the underlying causes of under nutrition and to plan and implement appropriate
interventions and programs to improve the situation, the government and partners must
identify the current nutritional status of both the population at large and vulnerable groups,
recognize changes in nutritional status over time, and acknowledge the context in which
challenges have surfaced. Sources of information that promote a deeper understanding of this
context and help identify potential responses include formal nutrition surveys, food security
surveys and records of malnutrition cases. Formal nutrition surveys are still the best way to
accurately estimate prevalence of malnutrition because they reveal trends in the number of
malnutrition cases and identify opportunities for action. Affected populations’ ability to cope at
a household level can also is assessed using food security surveys and records of malnutrition
cases found during screening at health centres. These are important when seeking a deeper
understanding of affected populations. However, these two tools cannot be considered
sufficiently representative of the population at large like a formal national nutrition survey is.
The last National Nutrition Survey was conducted in 2001/2002, almost 15 years after the
1985/1987 National Nutrition Survey. Almost a decade later, the current survey was undertaken
with the following goals:
� Establish the current nutrition benchmark and related indicators for gauging progress
toward the targets set for the Millennium Development Goals (MDGs);
� Establish a benchmark for missing data/indicators, especially since the recent
Demography and Health Survey (DHS) did not include anthropometric indicators.
� Prioritize the programs and initiatives at the national and provincial level and refine the
planning and implementation of initiatives on the basis of identified priorities.
| National Nutrition Survey 2011
6
1.4 Survey duration
Data collection began in January 2011 and was completed on 30 June 2011. The survey teams
underwent five days of extensive training led by senior and experienced staff from The Aga
Khan University who had experience conducting similar surveys in Pakistan and also abroad (Sri
Lank and Maldives). Training sessions and refreshers were conducted in Karachi, Faisalabad,
Lahore, Rawalpindi, Peshawar, Abbottabad, Quetta and Gawadar.
| National Nutrition Survey 2011
7
Chapter 2: Survey Design and Methods
2.1 Objectives
The specific objectives of the National Nutrition Survey 2011:
� Assess the population’s nutritional status, especially women and children.
� Collect data on height, weight and age of children under 5 years of age, women of
reproductive age and elderly persons.
� Collect blood specimens for micronutrient status assessments of children and women
of reproductive age – mainly vitamin A, zinc, vitamin D, calcium and iron.
� Collect urine samples to assess the iodine status of women of reproductive age and
children between 6–12 years of age.
� Assess infant and young child feeding and care practices, including breastfeeding,
complementary feeding and morbidity of children.
� Collect data on food intake, food security, water and sanitation.
� Collect data on demographic and socioeconomic variables.
2.2 Indicators for National Nutrition Survey
2.2.1 Anthropometric indicators
� Stunting rates
� Wasting rates
� Underweight rates
2.2.2 Clinical indicators
� Clinical prevalence of anaemia (physical examination)
� Visible goitre (physical examination)
� Night blindness (history based)
� Worm infestation (history based)
� Comorbidities (diarrhoea and acute respiratory infections - history based)
� Immunization status (history and immunization card)
2.2.3 Biochemical indicators
� Anaemia among women of reproductive age (WRA) and children under 5 years.
� Serum vitamin A, D, zinc and calcium levels among WRA and children under 5 years of age.
| National Nutrition Survey 2011
8
� Urinary iodine deficiency among WRA and children 6–12 years of age.
� Alpha-1 glycoprotein levels (acute phase reactant) of WRA and children under 5 years.
2.3 Survey design
A cross-sectional survey design was chosen to collect data to make inferences about a given
population at one point in time. Cross-sectional surveys provide a snapshot of the prevalence
and attributes of problems or detect normalcy in specific target populations. A cross-sectional
survey is a descriptive survey in which disease and exposure status is measured simultaneously
to discover information about households, physical examinations, anthropometry and
biochemical indicators.
2.3.1 Universe
The universe for this survey was comprised of all urban and rural areas of all four provinces of
Pakistan, the Federally Administered Tribal Areas (FATA), Azad Jammu Kashmir (AJK) and Gilgit
Baltistan (GB) defined as such by the 1998 Population Census, and the subsequent changes
made by the provincial governments periodically. The population of the military restricted areas
was excluded from the scope of this survey. Excluded areas constituted less than 1% of the total
population.
2.3.2 Sampling frame
A. Urban areas
The Federal Bureau of Statistics (FBS) has its own sampling frame for all urban areas of the
country. This frame is an area where each city and town is divided into a number of small
compact areas called enumeration blocks (EBs). Each enumeration block consists of between
200 to 250 households with well-defined boundaries, which are recorded on forms and maps
that also include physical features of the area and important landmarks.
Each enumeration block was classified into low, middle or high income groups – depending on
what income group the majority of the households located in that particular enumeration block
belonged to. This information was then used to formulate sub-stratification. This sampling frame
covers all urban areas of Balochistan with the exception of military restricted areas. There is a
continuous process of updating that occurs when newly built apartments, houses or extensions
emerge within the municipal limits of urban localities, towns and cities. Due to rapid growth in
these areas, the frame is regularly updated every 5 to 7 years. It was entirely updated in 2004.
There are 26,753 enumeration blocks in all urban areas of the country.
B. Rural areas
The sampling frame for rural areas consists of list of mouzas, dehs and villages. The Population
Census Organization (PCO) prepared it after a countrywide population census was conducted in
1998. A mouza, deh or village can be defined as the smallest “revenue estate” identified by its
| National Nutrition Survey 2011
9
name, and has the best number, cadastral map and name of Tehsil, District and Province in
which it is located. The rural sampling frame is comprised of 50,572 mouzas/dehs/villages and
has been used to draw the sample for this survey.
The information on the number of enumeration blocks in urban and rural areas of the country
are given below:
Table 2.1: Enumeration blocks and villages by Province and Region
Province Number of
Enumeration Blocks Number of Villages
Punjab* 14,900 26,007
Sindh 9,025 5,871
Khyber Pakhtunkhwa (KP) 1,936 7,334
Balochistan 618 6,555
Federally Administered Tribal Areas (FATA) 0 2,596
Azad Jammu Kashmir 210 1,643
Gilgit Baltistan 64 566
Total 26,753 50,572
*Including Islamabad
2.3.3 Listing activity
Fresh listing of households was undertaken in all sample areas after a comprehensive training of
the quantitative survey team was conducted. In urban areas, enumeration blocks were
considered as primary sampling units (PSUs). The sketch map of enumeration blocks drafted by
the Federal Bureau of Statistics (FBS) in urban areas was used to perform listings. In rural areas,
villages were taken as the PSUs, in line with the 1998 Population Census. Large sample villages
that have a population of more than 2,000 (according to the 1998 Population Census) were split
into hamlets/blocks of equal size. One of these blocks was selected randomly for data collection.
Small villages were completely listed. The listing of households was used to select a specified
number of households from urban and rural sample areas.
2.3.4 Stratification
A. Urban domain
i. Large sized cities
Karachi, Lahore, Gujranwala, Faisalabad, Rawalpindi, Multan, Sialkot, Sargodha, Bahawalpur,
Hyderabad, Sukkur, Peshawar, Quetta and Islamabad were considered “large sized cities”. Each
of these cities constitutes a separate stratum that was sub-stratified according to low, middle
and high income groups. The sub-stratification was based on information collected about each
enumeration block during demarcation when the urban area sampling frame was updated.
ii. Remaining urban areas
After excluding the population of large sized cities from the population of the respective
administrative division, the remaining urban population of each administrative division of the
| National Nutrition Survey 2011
10
four provinces was grouped together to form a stratum called “other urban areas”. Thus each
administrative division in remaining urban areas in the four provinces constituted a stratum. In
AJK, FATA and GB, all urban areas were grouped together within each region/state separately.
B. Rural domain
In the rural domain, each administrative district in the Punjab, Sindh and Khyber Pakhtunkhwa
provinces was considered as an independent and explicit stratum, whereas in Balochistan
province each administrative division constituted a stratum. In AJK, FATA and GB, all rural areas
were grouped together to form stratum within each region separately.
2.3.5 Sample size and its allocation
After considering a variety of characteristics including population distribution and field resources
available, a sample size of 30,000 households was selected as a sufficient number of households
to provide reliable results. An exercise to compute the sample size based on the prevalence rate
of three key variables – wasting in children under 5 years of age, stunting in children under 5
and maternal iron deficiency – was undertaken. The sample is estimated to have a 95%
confidence interval and a 5% margin of error. A 5% non-response rate was also considered. The
design effect of 1.6 was used to finalize and fix the overall sample size. The entire sample of
30,000 households (SSUs) was fixed comprising of 1,500 (PSUs) out of which 618 were urban and
882 were rural. As the urban population was more heterogeneous, a larger proportion of the
sample size was allocated to urban domain. As KP and Balochistan are smaller provinces, a
higher proportion of the sample size was allocated to these two provinces in order to get reliable
estimates. After fixing the sample size at provincial level, further distribution of sample PSUs into
different strata in rural and urban domains in each province was made proportionately. The
distribution of PSUs and SSUs enumerated in the urban and rural domain of the provinces and
regions is indicated below:
Table 2.2 Sample size and allocation plan
Province/Region
Number of sample PSUs Number of sample SSUs
Total Urban Rural Total Urban Rural
Punjab* 682 307 375 13,640 6,140 7,500
Sindh 323 157 166 6,460 3,140 3,320
KP 218 67 151 4,360 1,340 3,020
Balochistan 110 44 66 2,200 880 1,320
FATA 67 0 67 1,340 0 1,340
AJK 66 28 38 1,320 560 760
GB 34 15 19 680 300 380
Total 1,500 618 882 30,000 12,360 17,640
* Including Islamabad
2.3.6 Sample selection procedure
a) Selection of primary sampling units (PSUs)
| National Nutrition Survey 2011
11
Enumeration blocks in urban domain and mouzas/dehs/villages in rural domain were taken as
PSUs. In the urban domain, sample PSUs from each ultimate stratum/sub-stratum were selected
using the PPS method of the sampling scheme. In the rural domain, the number of households in
the enumeration block from the 2004 Economic Census and the population from the 1998
census for each village/mouza/deh were considered as the measure of size.
b) Selection of secondary sampling units (SSUs)
Households within the sample PSUs were taken as SSUs. A specified number of households (i.e.
20 from each urban and rural sample PSU) were selected with equal probability using a
systematic sampling technique with a random start.
2.3.7 Target population
The target population included women of reproductive age (15–49 years), children 6–59 months
and elderly persons (>50 years).
2.3.8 Survey methods
A method mix of quantitative and qualitative methods was adopted.
2.3.9 Description of questionnaire (quantitative)
A structured questionnaire was used to obtain the data. The questionnaire was developed using
standard components from previous and recent surveys undertaken nationally and
internationally. All the data collection tools were thoroughly assessed by the technical
committee established to oversee the NNS 2011. Three iterations of the survey instrument were
reviewed and the final version was approved in December 2010.
In Section 1 of module “A”, all members of each household were listed by their gender, age,
education, occupation and marital status. Besides such information, anthropometry (height,
weight and clinical examination for anaemia, jaundice, cyanosis, edema and goitre) was
conducted for anyone who was present at the time of the survey. Data corresponding to the
name of each member was recorded. Section 2 of module “A” was exclusively designed for
obtaining socioeconomic data along with health and hygiene characteristics. Knowledge,
attitudes and practices about micronutrients (iron, iodine, and vitamins A, B, C and D) were
recorded in the module “B” while module “C” focused on reproductive history, intra-birth
interval, antenatal care, night blindness, worm infestation, iron supplementation and
morbidities. Additionally, module “C” assessed dietary intake and food practices using a 24-hour
dietary recall to determine patterns of eating habits and variety of foods consumed over a
longer period of time by WRA.
The infant and young child feeding (IYCF) Module “D” was used to capture several indicators
including data on birth, newborn weight, resuscitation, breastfeeding initiation, complementary
feeding, micronutrients, 24-hour dietary recall and food practices for the youngest child. A
separate Module “E” was developed to determine the health status, immunization, physical
| National Nutrition Survey 2011
12
examination and lab investigation of children under 5 years of age. The appetite, movement,
mobility and morbidities of elderly persons were also investigated in Module “F”. The poverty
assessment and food security Module “G” was also filled-in.
2.3.10 Description of qualitative research
The overall aim was to identify food consumption patterns, nutrition and food behaviour as well
as to gain insight into the factors affecting decision-making. These factors include, the
connection between diet, disease and health, beliefs about certain foods, dietary practices, food
intake patterns, consumption of local versus imported foods, and other factors relating to food
choices.
2.3.11 Qualitative research sample and target population
In qualitative research, purposive sampling is the dominant strategy and purposive sample size is
often determined on the basis of theoretical saturation (FHI, 2005). A total of 40 focus group
discussions and 16 in-depth interviews were conducted. Participants were identified and
selected through the community recruiters at their living sites.
2.3.12 Transcription and translation of qualitative data
Data were transcribed and translated directly from the native language into English. The validity
of the translations and transcripts was checked through back translation of the sample sections.
2.3.13 Biochemical analysis
Important and essential biochemical evaluation of the assessment of micronutrient deficiencies
was performed on children under 5 years of age and women of reproductive age. Children
between 6–12 years of age and WRA were also assessed for urinary iodine. Details of the
biochemical test are shown in Table 2.3 below.
Table 2.3: Description of biochemical analysis/tests
Biochemical Test Children 0 month to 5 years Children 6 – 12 years WRA
Alpha-1 Glycoprotein Yes - Yes
Vitamin A Yes - Yes
Vitamin D Yes - Yes
Zinc Yes - Yes
Calcium - - Yes
Haemoglobin Yes - Yes
Ferritin Yes - Yes
Urinary Iodine Yes Yes Yes
| National Nutrition Survey 2011
13
2.3.14 Project pre-implementation steps
Before launching the field activities the following steps were undertaken:
Table 2.4: Pre-implementation steps
Formation of Technical
Committee
Technical committees – with representatives from the relevant stakeholders to
oversee technical aspects of the NNS 2011 – were notified.
Liaison with the local
partners
Liaison with partners:
• Federal Bureau of Statistics (FBS)
• Ministry of Health (MoH) and provincial health departments
• Pakistan Medical and Research Council (PMRC) – data collection in KP and FATA
Development of survey
manual
A detailed manual of operations for survey procedures was developed. This
encompasses qualitative and quantitative data collection strategies,
anthropometry guidelines, sample collection and transportation guidelines, and
data management strategies.
Development of consent
forms and survey
Instruments
The relevant consent forms and instruments were developed. The instruments
have different modules relevant to study participants.
Ethical Review Committee
(ERC) application
submission
Ethical review applications were submitted to National Bioethics and to AKU
ethics committees for approval of the methodology and consent forms.
Acquisition of sample
frame and design from
FBS
Worked closely with the FBS to develop the research design and sampling frame.
A sample size of 30,000 households and 1,500 enumeration blocks was proposed
and agreed to.
Establishment of survey
hubs: Punjab=8 (average
85 enumeration blocks per
one Hub), Sindh=5 (65), KP
and FATA=5 (57),
Balochistan=5 (22), AJK=3
(22) and Gilgit Baltistan=2
(17)
Survey hubs were established for the operational movement of field teams in the
following locations:
Sindh: Karachi, Hyderabad, Mirpurkhas and Sukkur
Punjab: RY Khan, Multan, DG Khan, Bahawalpur, Sahiwal, Faisalabad, Lahore and
Rawalpindi
KP and FATA: Abbottabad, Peshawar, Swat, D I Khan and Kohat
AJK: Muzaffarabad, Bagh and Mirpur
Gilgit Baltistan: Gilgit and Skardu
Balochistan: Gawadar, Khuzdar, Bella, Quetta, Dalbandin and Jaffarabad
2.3.15 Identification and recruitment of field staff
Advertisements (in-house and in the national daily newspapers) were placed and candidates
were shortlisted and interviewed in Karachi, Faisalabad, Rawalpindi, Peshawar and Quetta.
2.3.16 Survey teams
Initially 15 survey teams were established and more teams inducted as the survey progressed to
keep the momentum and to meet the time target. At one point, 22 teams were simultaneously
operating in different parts of the country. Each team consisted of 1 field supervisor, 1 team
| National Nutrition Survey 2011
14
leader, 4–5 data collectors, 3 registered nurses (with 1 phlebotomist), 2 logistic assistants and 2
community facilitators. Separate teams consisting of moderators and facilitators, observers,
note-takers and community recruiters were also established.
A. Staff profile
The staff team included a national survey coordinator, a senior survey coordinator and survey
coordinators. All the team supervisors were senior medical doctors and lead social scientists
with over ten years of experience in nutrition related surveys nationally and internationally. The
team included experienced female team leaders who were trained in social sciences. They
helped gain access to households to ensure the quality and validity of data. All data collectors
were at least university graduates supported by logistics assistants and local community
facilitators.
B. Separate teams for mapping and listing
Each team consisted of a FBS representative and a logistic assistant and were supported by local
community facilitators as they visited each EB/village prior to data collection for demarcation of
the EB/village as per FBS maps. During this exercise, all structures and households were listed
and allotted a unique ID (NNS 1, 2, 3 for structures and HH 1, 2, 3 for households). Additionally,
basic data including that of children under 5 years of age, the household head, women of
reproductive age and elderly persons above 50 years of age were obtained. From each of the
listed HHs in the EB, 20 HHs were randomly selected through a computerized process using
Microsoft Excel.
2.3.17 Training
Training sessions and refreshers were conducted in Karachi, Faisalabad, Lahore, Peshawar,
Abbottabad, Quetta and Gawadar. These sessions took place over a period of five days and were
carried out by staff from the department of paediatrics and child health of Aga Khan University
who had prior experience in similar surveys. Some of the details of the training agenda are
shown in Table 2.5.
Table 2.5: Details of the training agenda
Staff Training Components
All Staff Introduction to NNS Research design survey methodology
Team Leaders
Community rapport building, counselling techniques, research basics,
interviewing techniques, dress code, consent procedures, interpersonal
skills, ensuring high response, sampling methodology, question by
question explanation, mock interviews, operational procedures, field
procedures, daily documentation, log sheet completion, dealing with
refusals, spot checking, random checking and desk editing
| National Nutrition Survey 2011
15
Data Collectors
Community rapport building, research basics, interviewing techniques,
dress code, consent procedures, interpersonal skills, ensuring high
response sampling methodology, question by question explanation,
mock interviews, operational procedures, field procedures, daily
documentation, log sheet completion
Nurses Physical examination, anthropometry, field practice and urine sampling
Phlebotomists Blood sampling, safe injection practices, labelling and storage,
transportation of samples and field practice
Piloting/pre-testing
A pre-test was undertaken to pilot the questionnaire and to identify and solve unforeseen
problems before actual data collection. The objectives of the pre-test were to improve the
language of the questionnaire; establish the order of questions; check accuracy and adequacy of
the questionnaire instructions such as “skip” and “go to”; clarify the instructions to the
interviewers; eliminate unnecessary questions and add necessary ones; endeavour to lessen
discomfort, harm, or embarrassment to the respondent; improve translation of technical terms;
and estimate the time needed to conduct an interview.
Both the “participating” and “undeclared” pre-tests were undertaken. Participating pre-tests
were done in the classroom among the interviewers themselves while undeclared pre-tests were
done in the field without informing respondents that it was a pre-test.
About 100–150 respondents with reasonably similar characteristics from the survey population
were interviewed in different parts of Karachi. The questionnaire was then revised and finalized
on the basis of the pre-test results and direct observations by survey supervisors. The survey
coordinators also closely monitored the pre-testing.
2.3.18 Coding scheme for assigning processing
A seven-digit coding scheme was developed in order to provide processing codes to primary
sampling units [i.e. enumeration blocks/villages (PSUs)] and secondary sampling units [i.e.
households (SSUs)].
2.3.19 Plan of operation, training and monitoring
In order to ensure timely completion of the survey, effective tools were developed for periodic
field activity checks. A one step forward strategy was developed instead of the conventional
approaches of monitoring. Additionally, internal monitoring survey stakeholders including
Federal and Provincial Nutrition Wings, the Ministry of Health, the Government of Pakistan and
UNICEF were proactively engaged in the training sessions as well as in monitoring and evaluating
the progress of the survey activities. Besides this, independent and experienced monitors were
also engag
| National Nutrition Survey 2011
16
2.3.20 Data management, transfer and analysis plan
The filled-in questionnaires were first desk-edited at the field sites for completeness and
checked for major errors by the team leaders. Once this was complete, the questionnaires were
sent through a courier service to Aga Khan University’s Data Management Unit (DMU) in Karachi,
where a full time desk was established to receive the survey questionnaires, maintain log
registers and check for completeness. Where there was inconsistency or missing responses, the
editors flagged the errors/omissions and consulted the team leaders for clarification. Before
data entry, all questionnaires were coded for open-ended responses.
a. Software for data entry and analysis
Visual Fox Pro was used for designing the databases, data entry software and procedures for
data quality assurance. Range and consistency checks as well as skip patterns were built in the
data entry program to minimize entry of erroneous data. Special arrangements were made to
enforce referential integrity of the database so that all data tables were related to each other.
Analysis of data was undertaken using SPSS version 15.
b. Anthropometric data analysis
WHO Anthro (version 3.2.2, January 2011) was used for anthropometric analysis. However, ENA-
SMART software was used to check the day-to-day consistency of anthropometric data, which
helped to address measurement errors at the initial stages of data collection.
c. Data entry and quality checks
Two pass verification or double data entry was carried out for each filled-in questionnaire to
minimize keypunch errors. An error check program was also incorporated into the data entry
system to ensure quality of data. Data entry started after one week of data collection following
clearance by the survey coordinator and requisite data quality assurance.
2.3.23 Ethical approval and confidentiality
The survey design, sampling strategy and analytical plan were reviewed and approved by the
Aga Khan University’s Ethics Review Committee as well as by the National Bioethics Committee
(NBC) of the Government of Pakistan. Confidentiality of all collected data was assigned high
priority during each stage of data handling. All the names and personal information regarding
any individual were kept confidential and data sets were kept anonymous for analysis. Only
senior staff had access to the data. All data files have been protected by passwords and serum
and blood samples were duly secured, as per standard procedures of the institution.
| National Nutrition Survey 2011
17
Results of the
National Nutrition Survey 2011
| National Nutrition Survey 2011
18
Chapter 3: Background and Household Characteristics
3.1 Completion of data collection
The required sample size for data collection was 30,000 households. The survey teams were able
to approach the required number of households, however, 6.8% of the sampled households
refused to participate in the survey. A total of 27,963 households consented to participate in the
survey and interviews were conducted successfully. The refusal rate varied widely between
regions – the lowest being in AJK at 1.3% and the highest being FATA1 at 32.8%. This was
possibly related to the prevalent insurgency, security issues and accessibility in the FATA region.
A verbal consent was obtained from participating households prior to the interview for
permission to collect information and anthropometric measurements through a pre-printed
questionnaire. For blood draws, urine samples collection and clinical examination a written
consent was obtained.
The NNS 2011 coverage and population density maps for comparison of sample distribution and
population conglomeration are featured below:
Fig 3.1 Population density Fig 3.2 National Nutrition Survey coverage
Sample size coverage by provinces and regions is listed in the next table.
Table 3.1: Details of sample size coverage
1Data from FATA are not representative due to high non-response rate. This is given only as part of national data.
| National Nutrition Survey 2011
19
Number of PSUs and SSUs by Province / Region – Household Interviews Completed
Province /
Region
PSUs Household (HH) Interviews
Target Completed HH
Visited
Consent Refused HH
Completed
Refusal Rate (%)
Balochistan 110 110 2,200 204 1,996 9.3
Khyber
Pakhtunkhwa
218 218 4,360 734 3,626 16.2
FATA 67 67 1,340 440 900 32.8
Sindh 323 323 6,460 178 6,282 2.8
Punjab 682 682 13,640 452 13,188 3.3
AJK 66 66 1,320 17 1,303 1.3
Gilgit Baltistan 34 34 680 12 668 1.8
All Pakistan 1,500 1,500 30,000 2,037 27,963 6.8
3.1.1 Blood and urine specimen
Overall 24,421 blood samples (12,282 women and 12,139 children) were collected across Pakistan. The
survey teams also collected 2,900 urine samples from women (1,460) and children 6-12 years (1,457) for
biochemical assessments.
3.2 Background and household characteristics
The total population counted in the surveyed households was 187,095. Males slightly outnumbered
females (approximately 50.4% of the population were males and 49.6% females). The gender breakdown
was 101.6 males to 100 females, which differed from the last census conducted in 1998 that found 108.5
males for every 100 females. This is, however, similar to the 2006 Pakistan Demographic and Health
Survey statistics, which found 102 males for every 100 females. The data from FATA showed significant
gender imbalance – 123.2 males for every 100 females. However, in AJK it was 95.7 males per 100
females. The average household size was 6.7, which is similar to what was found in the 1998 census.
3.3 Formal education – head of household and mothers
In the NNS 2001, 37.9% of the household heads were illiterate. The proportion of illiterate heads of
household was lowest in AJK at 27.3%, whereas the proportion was highest in Balochistan at 58.2%.
Female literacy in Pakistan has been a challenge for many decades. The results of the NNS 2011 showed
that the proportion of illiterate mothers was 59.3% and the proportion was almost double in rural areas
than it urban areas (36.6% urban and 69.4% rural). Only 10.5% of mothers completed their 10 years of
schooling and 9.0% managed to complete their studies beyond grade 10. Data from the survey further
revealed that about 10.9% of mothers from rural areas received education up to 10th grade while in
urban areas 38.8% achieved the same.
The data also showed that females headed 6.2% of the households. The highest percentage of female
headed households was FATA (11.9%) and the lowest in Gilgit Baltistan (4.9%).
| National Nutrition Survey 2011
20
Fig 3.3: Formal education of mothers
3.4 Occupation – head of household
The NNS 2011 data showed that 53.6% of household heads were labourers, workers or farmers. Of these,
35.9% belonged to the urban population and 61.6% to the rural population. In comparison to the
previous findings in the NNS 2001, 16.6% of household heads belonged to the labour/worker/farmer
groups. Government and private service employees were the second largest group of those in
employment (16.4%). The figures showed that the proportion of unemployed heads of households had
doubled since 2001 (7.7% in 2001 compared to 15.5% in 2011).
3.5 Nature of dwelling by type of floor, roof and walls
The survey found that a large proportion of people living in urban and rural areas lacked basic civic
necessities. The NNS 2011 data show that 64% of famili